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Acute Gastroenteritis: Adult ______Gastrointestinal

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Acute Gastroenteritis: Adult ______Gastrointestinal Acute Gastroenteritis: Adult _____________________________ Gastrointestinal Clinical Decision Tool for RNs with Effective Date: December 1, 2019 Authorized Practice [RN(AAP)s] Review Date: December 1, 2022 Background Gastroenteritis, also known as enteritis or gastroenterocolitis, is an inflammation of the stomach and intestines that manifests as anorexia, nausea, vomiting, and diarrhea (Thomas, 2019). Gastroenteritis can be acute or chronic and can be caused by bacteria, viruses, parasites, injury to the bowel mucosa, inorganic poisons (sodium nitrate), organic poisons (mushrooms, shellfish), and drugs (Thomas, 2019). Chronic causes include food allergies and intolerances, stress, and lactase deficiency (Thomas, 2019). Gastroenteritis caused by bacterial toxins in food is often known as food poisoning and should be suspected when groups of individuals present with the same symptoms (Thomas, 2019). Immediate Consultation Requirements The RN(AAP) should seek immediate consultation from a physician/NP when any of the following circumstances exist: ● moderate dehydration (six to 10% loss of body weight), and blood pressure and mental status do not stabilize in the normal range within one hour of initiating rehydration therapy; ● severe dehydration (>10% loss of body weight); ● high fever and appears acutely ill; ● tachycardia or palpitations; ● hypotension; ● severe headache; ● blood or pus in stool; ● severe abdominal pain; ● abdominal distention; ● absent bowel sounds; ● altered mental status; ● older and immunocompromised clients; and/or ● severe vomiting (Interprofessional Advisory Group [IPAG], personal communication, October 20, 2019). GI | Acute Gastroenteritis - Adult The RN(AAP) should initiate an intravenous fluid replacement as ordered by the physician/NP or as contained in an applicable RN Clinical Protocol within RN Specialty Practices if any of the ​Immediate Consultation​ circumstances exist. Classification of Gastroenteritis Infectious Non-infectious Acute gastroenteritis is most often caused by Acute gastroenteritis can also be caused by an infectious agent. The most common mode dietary factors, medications, and metabolic factors of transmission is the fecal-oral route from such as: contaminated food or water (Thomas, 2019). ● coffee, Bacterial pathogens cause approximately 30 ● tea, to 80% of cases. Viral, and parasitic ● sodas containing caffeine, pathogens may also cause gastroenteritis ● antacids, (Huether, 2019). ● antibiotics, Common causes may include: ● diabetes mellitus, Bacterial: ● hyperthyroidism, ● Campylobacter jejuni ● adrenal insufficiency. ● Shigella ● Salmonella ● Enterohemorrhagic ​Escherichia coli ● Clostridium difficile (C.​ ​difficile) Viral: ● Rotavirus ● Norovirus virus Parasitic: ● Giardia lamblia ● Cryptosporidium ​(Huether, 2019; Thomas, 2019) Predisposing and Risk Factors Predisposing and risk factors for acute gastroenteritis in adult clients include: ● recent travel to ​developing countries​, ● immunocompromised clients, ● anal intercourse, ● residents of institutions or nursing homes, ● consumption of raw shellfish and seafood, ● consumption of contaminated food or water, ● crowded living conditions, and/or ● antibiotic and/or antacid use (Thomas, 2019). 2 RN(AAP) Clinical Decision Tools ©2019 Saskatchewan Registered Nurses Association GI | Acute Gastroenteritis - Adult Health History and Physical Exam Subjective Findings The circumstances of the presenting complaint should be determined. These include: ● onset (abrupt or gradual) and duration of symptoms; ● alleviating or provoking factors; ● contact with someone with similar symptoms; ● degree of nausea, vomiting, and diarrhea; ● fever; ● abdominal pain or cramping; ● fatigue, malaise, anorexia, tenesmus, borborygmus (presence of symptoms depends on underlying condition); ● symptoms of dehydration; ● characteristics of feces (frequency, amount, fluidity, and colour); ● diet history, including food intolerances; ● recent travel; ● exposure to animals (e.g., reptiles which may harbour Salmonella, pets with diarrhea, or a recent visit to a farm or petting zoo); ● source of drinking water; ● intake of untreated water (e.g., swimming in a stream or lake); ● medications (e.g., antibiotics, antacids); ● medical/surgical history; ● sexual practices, including anal intercourse; ● social history, including living conditions, illicit drug use, alcohol use; and/or ● family history (e.g., colon cancer, inflammatory bowel disease) (Thomas, 2019). Objective Findings The physical examination is usually normal in adults presenting with acute gastroenteritis, except for the gastrointestinal symptoms identified in ​Subjective Findings section (Thomas, 2019). The physical examination should look for signs of dehydration including: ● altered mental status; ● decreased capillary refill; ● decreased skin turgor which is tested on inner aspect of thighs or the skin overlying the sternum, and is less reliable in older clients due to decreased skin elasticity with age; ● dry mucous membranes of the tongue and oral mucosa; 3 RN(AAP) Clinical Decision Tools ©2019 Saskatchewan Registered Nurses Association GI | Acute Gastroenteritis - Adult ● orthostatic hypotension, which is determined by taking supine blood pressure after the client is laying down for five to 10 minutes, and then taking the blood pressure as soon as the client sits or stands up, and again in this position after two to three minutes. A drop in systolic blood pressure ≥ 20 mmHg or a drop in diastolic blood pressure ≥ 10 mmHg from supine indicates orthostatic hypertension; and ● weight loss (Sterns, 2017). The RN(AAP) should be cognizant that: ● classical signs of dehydration such as loss of skin turgor, increased thirst, and orthostatic hypotension have a low sensitivity in older adults. ● dehydration may cause atypical symptoms such as confusion, constipation, fever, and falls (Hooper, 2016; Huang, 2018; Sterns, 2017). The following table can assist in determining the level of dehydration in adult clients, noting that moderate and severe dehydration require immediate consultation to a physician/NP. Physical Findings in Association with Degree of Dehydration Clinical Sign Mild Dehydration Moderate Severe Dehydration Dehydration Estimated fluid loss (% of < 6% 6-10% > 10% body weight) Level of consciousness alert lethargic obtunded or comatose Capillary refill 2 sec 2-4 sec > 4 sec, cool limbs Mucous membranes normal dry parched, cracked Heart rate normal or slightly increased very increased increased Respiratory rate/pattern normal increased increased and hyperpnea Blood pressure normal normal, but decreased abnormal orthostatic Pulse normal thready faint or impalpable 4 RN(AAP) Clinical Decision Tools ©2019 Saskatchewan Registered Nurses Association GI | Acute Gastroenteritis - Adult Skin turgor (over sternum normal slow tenting or inner aspect of thigh) Eye appearance normal sunken very sunken Urine output decreased oliguria oliguria/anuria (Huang, 2018) Differential Diagnosis The following should be considered as part of the differential diagnosis: ● viral infection, ● bacterial infection, ● parasitic infection, ● diet induced (e.g., excess consumption of alcohol or fruit), ● medication induced (e.g., current or recent antibiotic use, laxatives, supplements), ● irritable bowel syndrome (IBS), ● inflammatory bowel disease (Crohn's colitis, ulcerative colitis, ischemic colitis), ● ischemic bowel disease, ● partial bowel obstruction, ● pelvic abscess, ● malabsorption syndrome (e.g., lactase deficiency), ● acute psychosocial stress/anxiety, ● any surgical alteration of the GI tract, or ● complications from diabetes mellitus, small bowel diverticulosis, Whipple’s disease, or chronic pancreatitis (Thomas, 2019). Making the Diagnosis Systematically ruling out all differential diagnoses through history, physical, and diagnostic testing where appropriate can help lead to a definitive diagnosis. Caution should be exercised in making the diagnosis and attributing gastrointestinal symptoms only to acute gastroenteritis. The following table may help identify the diagnosis. 5 RN(AAP) Clinical Decision Tools ©2019 Saskatchewan Registered Nurses Association GI | Acute Gastroenteritis - Adult Clues to Underlying Etiology Sign or Symptom Potential Cause Bloody stool Bacterial pathogen such as: ● Shigella ● Salmonella ● Campylobacter ● Enterohemorrhagic​ Escherichia coli Symptoms present after eating hamburger meat E. coli Persistent diarrhea (> 2 weeks) ova and parasites Recent travel to Russia, Nepal, Rocky ova and parasites Mountains or other mountainous regions Exposure to infants in a daycare centre ova and parasites Men who have sex with men ova and parasites Symptoms after initiation of antibiotics and the C. difficile month following completion Vomiting as main symptom viral pathogen Suspected food or waterborne contamination viral pathogen Frothy stools and flatus malabsorption ​(Thomas, 2019) Investigations and Diagnostic Tests Laboratory tests are not usually necessary in clients with non-bloody diarrhea and no evidence of systemic toxicity (Thomas, 2019). Selection of the appropriate tests is based on the history and physical exam (Thomas, 2019) as well as through consultation with a physician/NP, as in most cases clients requiring testing are acutely ill. Stool testing for culture and sensitivity, ova and parasites, and ​C.​ ​difficile​ toxin, may be considered in clients with severe bloody diarrhea, fever of ≥ 38.5°C and symptoms on return from travel (Thomas, 2019). 6 RN(AAP) Clinical
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